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1
Otolaryngology Potpourri
Robert C. Langan, MD, FAAFP
Program Director
St. Luke’s Family Medicine Residency
Bethlehem, PA1
Neither I nor my family have any financial interest or relationship with any proprietary entity producing
health care goods or services
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Goals & Objectives
1. Review pertinent ENT anatomy2. Describe presentations, signs, and symptoms
of common ENT disorders as well as laboratory and diagnostic studies
3. Discuss non‐pharmacologic and pharmacologic therapy of common ENT disorders
4. Identify indications for ENT referral
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2
According to the IDSA, which antibiotic is first line for the treatment of acute bacterial sinusitis?
A. High‐dose amoxicillin
B. Amoxicillin‐clavulanic acid
C. Trimethoprim‐sulfamethoxazole
D. Levofloxacin
E. Clarithromycin
4
According to the AAP, diagnosis of acute otitis media requires which of the following?
A. Moderate to severe middle ear effusion (MEE)
B. New onset otorrhea without otitis externa
C. Mild MEE AND <48 hours of ear pain/erythema of the tympanic membrane
D. A or B or C
E. A and B and C
5
The preferred first line treatment for allergic rhinitis is:
A. Sedating antihistamines
B. Non‐sedating antihistamines
C. Intranasal corticosteroids
D. Intranasal cromolyn
E. Leukotriene receptor agonists
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3
Outer Ear
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Otitis Externa• 98% caused by bacteria (Pseudomonas, Staph aureus)
• RF: swimming, eczema, seborrhea, trauma
• Diagnosis:
– Acute onset AND ear pain AND ear canal edema/erythema
– Fever, otorrhea, lymphadenitis, TM erythema unnecessary
• Treatment:
– Effective (NNT = 2)
– No evidence that 1 topical antibiotic is superior to another
– Topical steroids improve resolution of symptoms
– No RCT evaluating preventive measures (ear plugs, acetic acid, avoiding self cleaning)
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Necrotizing Otitis Externa
• Formerly called “malignant” OE
• Usually caused by Pseudomonas
• More common in diabetics, elderly
• Spread of infection from canal to temporal bone
• Presents with severe ipsilateral ear pain
• Urgent ENT evaluation:– Debridement
– IV and topical anti‐Pseudomonal antibiotics
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4
Middle Ear
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Acute Otitis Media Guideline
• AAP (2013), endorsed by AAFP
• Applies to healthy children aged 6 months to 2 years
• Diagnosis requires:
– Moderate to severe middle ear effusion (MEE) OR
– New onset otorrhea without otitis externa OR
– Mild MEE AND <48 hours of ear pain/erythema of TM
• Parental suspicion of OM and ear tugging have the highest positive likelihood ratio (3)
• Treat pain (how to treat not specified)
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5
When to Treat AOM
AGE SEVERE* NONSEVERE
6 months‐23 months
Antibiotics Antibiotics for bilateral OMAntibiotics or observation**for unilateral OM
>24 months Antibiotics Antibiotics or observation**for bilateral OR unilateral OM
*SEVERE: Moderate/severe otalgia, otalgia for >48 hours, temperature >102.2° F (39° C)
**OBSERVATION requires follow up with initiation of antibiotics if symptoms do not improve in 48-72 hours.
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AOM Initial Treatment
• High‐dose amoxicillin (90 mg/kg/day) is the preferred 1st line antibiotic for patients who are not allergic AND have not received amoxicillin in the last 30 days
• If amoxicillin has been used in the last 30 days OR conjunctivitis is present, high dose amoxicillin‐clavulanic acid is recommended
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AOM Treatment
• PCN Allergic (non‐severe)
– Cefdinir 14 mg/kg/day in 1 or 2 daily doses
– Cefuroxime 30 mg/kg/day in 2 daily doses
– Cefpodoxime 10 mg/kg/day in 2 daily doses
– Ceftriaxone 50 mg/kg/day IM
• Clindamycin 30‐40 mg/kg/day in 3 daily doses
• Macrolides, TMP/SMX not recommended
• DURATION: 10 days (<2 years old)7 days (>2 years old)
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6
Other AOM Pearls
• Prophylactic antibiotics not recommended
• Consider PE tubes for 3 episodes of AOM/6 months OR 4 episodes/12 months
• Encourage exclusive breastfeeding for the first 6 months
• Avoid passive tobacco exposure
• Appropriate vaccinations
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OTITIS MEDIA WITH PERFORATION
1. Otorhea + AOM: Treat like AOM.2. Traumatic Perforation: Small perforations (<30%) usually heal
spontaneously in 4-6 weeks. Large perforations or perforations in specific professions (i.e. pilots) need ENT.
3. Keep ear dry.4. Avoid ototoxic eardrops (gentamicin, neomycin, tobramycin).5. Pain from AOM DECREASES with perforation; if pain
INCREASES consider mastoiditis. 17
SEROUS OTITIS MEDIA
1. May be post-AOM (4-6 weeks).2. Other causes include AR, exposure to tobacco, other URI.3. More common in children; usually asymptomatic.4. Treat underlying conditions (i.e. allergic rhinitis, avoidance of
tobacco).5. Hearing test for speech delay, persistent (>4-6 months) SOM.6. Role of PE tubes.
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7
TYPE A: NORMAL TYPE B: MIDDLE EAR FLUID
TYPE C: SINUS/ALLERGY
CONGESTION
TYMPANOGRAMS
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Hearing Loss
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Screening for Hearing Loss: Infants
• All newborns should be screened for hearing loss prior to 1 month of age (USPSTF B)
• OtoacousticAuditory brainstem response
• Children who fail both should see ENT/audiology within 3 months
• RF: NICU ≥ 2 days
Family History of hereditary hearing loss
Craniofacial abnormalities
Congenital syndromes
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8
Screening for Hearing Loss: Geriatrics
• Inadequate evidence to recommend for or against screening for hearing loss in adults (USPSTF I)
• Increasing age is the leading RF for hearing loss
• Hearing aids improve self‐reported hearing, communication, and social functioning
• Prevention: Avoid loud noises
Hearing protection
Tobacco cessation
Check medications
22
Hearing Loss
• CONDUCTIVE: hearing loss due to the conductive pathway of the ear– Cerumen impaction, swelling of external auditory canal, TM perforation, effusion
• SENSORINEURAL: hearing loss due to problems with the inner ear/8th cranial nerve; most common type of hearing loss– Persistent noise exposure, presbycusis, familial/genetic factors, postinflammatory, tumor
23
Testing for Hearing Loss
WEBER TEST
• Tuning fork on forehead
• Sound radiates to side with conductive hearing loss
• Sound radiates away from sensorineural loss
RINNE TEST
• Tuning fork at mastoid, then ear
• Should still hear sound
• Abnormal in conductive loss
• Unhelpful for sensorineural loss
Audiology evaluation is superior to both Weber and Rinne for evaluation of hearing loss.
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9
Hearing Loss Pearls
• Sudden sensorineural hearing loss: ENT evaluation
• Unilateral hearing loss in adults: consider acoustic neuroma; test of choice is MRI
• Unilateral hearing loss + tinnitus + dizziness: consider Ménière’s Disease
• Avoid loud noises for 14 hours prior to hearing tests
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Dizziness
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Dizziness
• May encompass dysequilibrium, syncope, lightheadedness, or vertigo
• VERTIGO: the sensation of spinning or whirling that occurs as a result of a disturbance in balance
• Causes: vestibular neuritis (labyrinthitis), benign paroxysmal positional vertigo, Ménière’s Disease
27
10
Vestibular Neuritis
• One of the most common etiologies of vertigo
• Caused by inflammation of the vestibular portion of the 8th cranial nerve
• Usually viral; may occur after URI
• Intense symptoms that improve over several days; hearing unaffected
• Nausea and/or vomiting common
• Treat with vestibular suppressant medication (meclizine) short term, fluids
28
BPPV
• Caused by otoconia (calcium carbonate crystals) that have become free floating and enter one of the semicircular canals
• Sudden turning of the head/arising from bed in the morning creates intense vertigo that lasts for less than 30 seconds
• Meclizine ineffective
• Treat with Dix‐Hallpike maneuver, vestibular therapy
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11
Ménière’s Disease
• Precise etiology unknown; thought to be due to distention of endolymphatic space
• Intense, episodic vertigo (lasting minutes to hours) associated with hearing loss, tinnitus
• Treatment is difficult
• ENT evaluation, salt restriction, thiazide diuretics
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Facial Nerve Disorders
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Facial Nerve Paralysis
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12
Bell’s Palsy
•Sudden onset, unilateral
•Idiopathic, but felt to be due to HSV 1
•Do not routinely screen for Lyme Disease, DM
•Imaging if symptoms do not improve with treatment
•Prednisone 60-80 mg daily x 7 days; start as soon as possible
•No evidence for effectiveness of antivirals + prednisone
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Ramsay Hunt Syndrome• Varicella zoster infection of
geniculate ganglion of facial nerve
• Facial nerve paralysis accompanied by severe pain and vesicular eruption in external auditory canal; pain precedes rash by hours to days
• Rash may not be present
• May represent up to 20% of cases of Bell’s Palsy
•No good evidence that antivirals, corticosteroids help but usually treated similarly to Bell’s Palsy•Less likely to have complete resolution compared to Bell’s Palsy
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Allergic Rhinitis
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13
AR Definitions (AAOHNS, 2014)• Inflammatory, IgE‐mediated disease
• Characterized by nasal congestion, rhinorrhea, sneezing, nasal itching
• May be classified according to:
– Temporal Pattern (seasonal, perennial, episodic)
– Frequency of symptoms (intermittent, persistent)
– Severity (mild, severe)
• Classification scheme clinically not useful
• PE: clear rhinorrhea, nasal congestion, pale nasal mucosa, red/watery eyes
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AR Pearls
• Recommend allergy testing only for patients who do not respond to empiric therapy, when the diagnosis is uncertain, or when knowledge of specific allergens is needed to target therapy
• Do not routinely recommend imaging for patients
• Environmental modification may be recommended
• Evaluate patients for asthma, atopic dermatitis
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AR Treatment
• Nasal steroids are first line medical treatment
• Non‐sedating antihistamines (NSAH) for patients with primarily sneezing/itching
• Leukotriene receptor antagonists (LTRA) should not be primary therapy UNLESS asthma is also present
• Combination therapy is reasonable if monotherapy does not control symptoms
• Recommend immunotherapy for patients who fail combination therapy
• No recommendations about herbal therapy based on lack of strong evidence
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14
Sinusitis
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Signs and Symptoms of Sinusitis
Sign/Symptom PPV NPV
Preceded by URI 81% 88%
Facial pain/pressure/fullness 77% 75%
Purulent rhinorrhea 61% 55%
Maxillary toothache 56% 59%
Nasal obstruction 43% 35%
DIAGNOSIS OF ACUTE SINUSITIS:Up to 4 weeks of purulent rhinorrhea accompanied by nasal obstruction OR facial pain/pressure/fullness
(AAOHNS, ACP, AAFP, IDSA)41
Acute Bacterial Rhinosinusitis
• IDSA (2013) recommends treatment for:
– Persistent and not improving (≥ 10 days)
– Severe symptoms (≥ 3‐4 days) OR
– “Double sickening”
• Assess risk of antibiotic resistance
– Age <2 years or >65 years
– Antibiotics within the past month
– Hospitalized in the past 5 days
– Co‐morbidities (incl. immunocompromised)
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15
Acute Bacterial Rhinosinusitis
• Low Risk of Resistance:
– 1st Line antibiotic x 5‐7 days
• High Risk of Resistance:
– 2nd Line antibiotic for 7‐10 days
• Worsening:
– Broaden coverage, consider imaging/ENT evaluation
1st LINE: Amoxicillin/Clavulanate2nd LINE: Amoxicillin/Clavulanate (high dose; 2 grams/day)PCN ALLERGIC: Doxycyline or Respiratory Fluoroquinolone or Clindamycin AND Cefiximine
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Acute Bacterial Rhinosinusitis
• Adjuvant Therapy:
– Intranasal Steroids (h/o AR)
– Saline irrigation
• NOT Recommended:
– Topical decongestants
– Oral decongestants
– Antihistamines
44
Chronic Sinusitis
DEFINTION (AAOHNS)
At least 2 of the following for >12 weeks:
A. Facial pressure/pain
B. Nasal obstruction*
C. Nasal discharge*
D. Reduction in smell
At least 1 of the following signs of inflammation:
A. Nasal polyps (rhinoscopy/endoscopy)
B. Edema/purulence of middle meatus
C. Inflammation on CT of paranasal sinuses45
16
Chronic Sinusitis Recommendations (JAMA 2015)
• Topical steroids for all patients ( Grade A)
• High volume (>100 mL) saline irrigation for all patients ( Grade A)
• AR: Consider NSAH, LTRA
• Sinus surgery for persistent symptoms (Grade C)
POLYPS NO POLYPS
Oral steroids (14‐21 d) Clarithromycin (90 d)
Doxycycline (21 d) Oral steroids (14‐21 d)
Culture (per ENT) Culture (per ENT)
AR: Allergic Rhinitis; NSAH: Non-Sedating Antihistamine; LTRA: Leukotriene-Receptor Antagonist 46
Salivary Gland Disorders
47
Salivary Gland Disorders
• Acute suppurative sialadenitis:
– Bacterial infection (usually S. aureus) after duct obstruction
– More common in hospitalized, debilitated patients, use of anticholinergic medications
– Affects 1 gland, usually parotid
– Warm compresses, oral hygiene, antibiotics, ? drainage
• Recurrent/chronic sialadenitis:
– Repeated episodes of sialadenitis causes fibrosis of duct
– Imaging, ENT to try to identify cause of obstruction
– Surgical therapy
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17
Salivary Gland Disorders
• Bilateral salivary gland enlargement: viral infection, HIV, autoimmune disorder (Sjögren’s disease)
• Mumps is the most common cause of non‐suppurative acute sialadenitis
– Vaccination has decreased the incidence by 99%
• Salivary gland tumors are uncommon
– Red Flags: pain, facial paresis, fixation of the mass, associated lymphadenopathy
– Parotid tumors usually benign, submandibular/ submaxillary more likely to be malignant
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Head and Neck Cancer
50
Head & Neck Cancer Pearls
• SCC most common type of primary cancer
• Biopsy lymph nodes present for greater than 6 weeks OR if constitutional symptoms are present
• Be suspicious of hard and nonmobile lymph nodes
• Traditional risk factors: abuse of tobacco, alcohol
• HPV‐associated oropharyngeal cancer
– Younger age, associated with oral sex, better survival, better response to treatment
– Presents with neck mass, sore throat, dysphagia
– HPV vaccines seem to be effective at ↓ incidence
• Contrast‐enhanced CT is the imaging test of choice51
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Questions?
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References1. Wax, MK. Primary Care Otolaryngology, 2nd Edition. American Academy
of Otolaryngology—Head and Neck Surgery Foundation. 2004.
2. www.entnet.org
3. Wilson KF, et al. Salivary gland disorders. Am Fam Physician 2014;89(11):882‐8.
4. Albers JR, Tamang S. Common questions about Bell’s palsy. Am Fam Physician 2014;89(3):209‐12.
5. Uscategui T, Doree C, Chamberlain IJ, Burton MJ. Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006851.
6. Uscategui T, Doree C, Chamberlain IJ, Burton MJ. Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006852.
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References7. Rudmik L, Soler ZM. Medical therapies for adult chronic sinusitis: a
systematic review. JAMA 2015;314(9):926‐39.
8. Moore KA, Mehta V. The growing epidemic of HPV‐positive oropharyngeal carcinoma: a clinical review for primary care providers. J Am Board Fam Med 2015;28:498‐503.
9. Haynes J, et al. Evaluation of neck masses in adults. Am Fam Physician 2015;91(10):698‐706.
10. Harmes KM, et al. Otitis media: diagnosis and treatment. Am Fam Physician 2013;88(7):435‐40.
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